Arthoscopic method and apparatus for tissue attachment to bone

ABSTRACT

Bone constructs of a patient are used to arthroscopically attach sutures to torn or dysfunctional tissue. Suture is passed through intersecting tunnels formed in the bone. An end of the suture extends from each of the tunnels, and the ends are used to secure the tissue to the bone, such as by arthroscopic tying of the ends, and pulling the tissue against the bone. Devices for achieving the process are also described.

FIELD OF THE INVENTION

The invention relates to methods and devices and more specificallyrelates to the arthroscopic fixation of tissue to bone using sutures.

BACKGROUND OF THE INVENTION

Invasive and open surgery methods of attachment of tissue to bone torepair tissue is known and used. An example of this method is rotatorcuff surgery. In some processes, foreign objects, such as sutureanchors, staples or screws, are implanted and used to connect tissue tobone.

SUMMARY OF THE INVENTION

The present invention overcomes the invasive nature of tissue repairs byopen surgical processes, and reduces the reliance on implants associatedwith arthroscopic repairs. The invention uses the bone constructs of thepatient to attach sutures to torn or dysfunctional tissue. Suture ispassed through intersecting tunnels formed in the bone. An end of thesuture extends from each of the tunnels, and the ends are used to securethe tissue to the bone, such as by arthroscopic tying of the ends, andpulling the tissue against the bone.

DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a rotator cuff drill guide in place with a trephinepiercing a torn rotator cuff. A single stand of suture is shown passingthrough the drill guide, rotator cuff tissue, into and out of thehumeral head, and exiting the central lumen of the trephine.

FIG. 2 illustrates three arthroscopic simple stitches, a repairedrotator cuff, and two lateral vertical portals.

FIG. 3 illustrates two arthroscopic mattress stitches where the initialsuture in the center bone tunnel was used to pass two sutures.

FIG. 4A is the drill guide assembly having an arcuate drill guide, astraight drill guide and a handle.

FIG. 4B is the stylus for the arcuate drill guide lumen.

FIG. 4C is the trephine guide pin that will fit into the straight drillguide lumen with enough clearance for the trephine.

FIG. 4D is the arthroscopic trephine.

FIG. 4E is an offset hook probe that will pass into the trephine.

FIG. 4F is a suture stylus with suture loosely attached.

FIG. 5 illustrates insertion of the arcuate lumen rotator cuff drillguide leading with the stylus.

FIG. 6 illustrates the stylus that has been passed through the straightdrill guide lumen.

FIG. 7 illustrates the trephine inserted to a calibration point thatadvances the tip past the bone void left by the stylus.

FIG. 8 illustrates the trephine partially retracted to a secondcalibration mark, the suture stylus with suture being advanced and thehook probe in a readied position.

FIG. 9 illustrates the suture lodged in the bone void left by the stylusafter being left behind by the suture stylus, and the hook probe whichhas been passed through the trephine to capture the suture.

FIG. 10 demonstrates an embodiment of the device using straight, butnon-parallel drill guides.

FIG. 11 demonstrates an embodiment of the device showing an additionalconfiguration of an arcuate drill guide.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

A preferred embodiment of the invention is demonstrated in repairing arotator cuff. Two arthroscopic portals 30,32 are formed in the shoulder34, such as by a scalpel. The humeral head 36 and rotator cuff tendons38 are present. An arcuate drill guide 16 having a central lumen isinserted into one of the portals. If required, cortical bone may beremoved prior to insertion of the arcuate drill guide.

The central lumen of the arcuate drill guide has a protruding flexiblestylus 4 therein that is advanced into the humeral head lateral of thetorn rotator cuff. The stylus may be formed of nitinol. The stylus mayhave a cutter formed in an end thereof, such as a drill or mill typecutter. In this embodiment, the forward end of the arcuate drill guideis curved. Advancement of the arcuate drill guide may be by manualpressure or by assisted manual force using, for example, a mallet, or bya power tool, such as a drill. The arcuate drill guide forms an arcuatetunnel in the bone. After the arcuate drill guide is fully advanced, thedrill guide stylus is withdrawn, leaving a small void in the bone thatis present beyond the leading edge of the arcuate drill guide. FIG. 6.

As shown in FIG. 1, straight drill guide 2 is placed through the otherportal. The straight drill guide has a lumen therein. A stylus is 24positioned within this lumen. The stylus may be formed of nitinol.Sufficient space is present within the lumen for placement of thetrephine 6, so that the stylus has a sloppy fit within the drill guide.The stylus pierces the tissue.

The trephine is inserted into the lumen of the straight drill guide. Thetrephine has a larger diameter than the stylus, but will rotate withinthe lumen. The trephine enlarges the tunnel, and is moved past thearcuate shaped tunnel formed using the arcuate drill guide. FIG. 7.

The trephine is retracted. As shown in FIG. 8 the trephine may havecalibration marks 20, 22 to indicate the depth of insertion andretraction of the trephine. The bone tunnels intersect as shown.

With the trephine in place, but with the styli removed from the drillguides, one or more strands of suture 14 are passed through the lumensof the drill guides, through a reapproximated rotator cuff tear, andthrough the two converging bone tunnels. The suture also passes throughthe humeral head (bone), and exits the central lumen of the trephine.The suture is advanced through the arcuate drill guide by the suturestylus 12. The hook probe 10 is inserted through the lumen of thetrephine to hook the suture advanced by the suture stylus atapproximately the intersection of the tunnels. FIG. 9.

Removal of the drill guides 2,16 leaves the suture in place for tying.Multiple suture passes allow for tying of the suture material. Forexample, three (3) suture passes allow tying three (3) simple stitches40 as shown in FIG. 2.

FIG. 3 shows two arthroscopic mattress stitches 42 where the initialsuture in the center bone tunnel was used to pass two sutures. The twosutures were tied twice with their adjacent sutures to form mattressstitches. Alternatively, the outside suture strands could have been usedto pull the corresponding central suture into the outside tunnel,resulting in one less knot left in the patient, and the opportunity touse a sliding knot.

The arcuate drill guide and the straight drill guide may be connected bya handle 44. The handle positions the relative angles of the drillguides for forming the tunnels as described. The drill guides arepositioned by the handle so that intersecting tunnels are formed asdisclosed herein. Both drill guides could be straight, with the drillguides angled in a non-parallel fashion to form intersecting tunnels.The handle may also be used to receive and transfer a force foradvancing the drill guides, such as by striking the handle with amallet.

Benefits of the present invention over the use of suture anchors includethe introduction of minimal foreign material in the patient, a larger“healing footprint” (which is variable with the distance between lumens)and the use of lumens as injection ports for plate rich/poorblood/growth factors. This method of arthroscopic bone/suture tunnelcreation also has applications in shoulder laberal repair and posteriorcruciate ligament and anterior cruciate ligament repair, without, or atleast reducing, the requirement of suture anchors, staples or screws.The geometry of the apparatus relates to an arthroscopic creation ofbone tunnels and simultaneous suture passing to repair a torn orpartially torn rotator cuff.

FIG. 10 shows the method of arthroscopic attachment of tissue to bonewhere different drill guide configurations are used to address theanatomic structure of the genohumeral joint, which are different thatrotator cuff repair. FIG. 10 shows parallel drill guide lumens 102,103that are useful for superior labrum deficiencies or tears.

FIG. 11 shows a drill guide that is similar to the rotator cuff guide,having one arcuate lumen 216 and one straight lumen 202 but having adifferent converging angle for inferior laberal repair. Aside from thesedifferences in the apparatus, the method of arthroscopic securing tissueto the glenoid is the same as described for attaching the rotator cuffto the humeral head.

1. A method of attachment of tissue to bone, comprising the steps of: a)arthroscopically forming a first tunnel in a bone; b) arthroscopicallyforming a second tunnel in said bone, wherein said first tunnelintersects said second tunnel; c) passing a suture though said firsttunnel and said second tunnel, wherein an end of said suture extendsfrom an opening to said first tunnel and an opposite end of said sutureextends from an opening to said second tunnel; and d) securing saidfirst end of said suture and said second end of said suture over tissueto pull said tissue against said bone.
 2. A method of attachment oftissue to bone as described in claim 1, wherein at least a portion ofsaid first tunnel is not parallel to said second tunnel.
 3. A method ofattachment of tissue to bone as described in claim 1, wherein said firsttunnel is not linear.
 4. A method of attachment of tissue to bone asdescribed in claim 1, wherein said first tunnel does not pass through toan opposite side of said bone from a side of entry into said bone.
 5. Amethod of attachment of tissue to bone as described in claim 1, whereinsaid first tunnel does not pass through to an opposite side of said bonefrom a side of entry into said bone, and said second tunnel does notpass through to an opposite side of said bone from said side of entryinto said bone.
 6. A method of attachment of tissue to bone as describedin claim 1, wherein said first tunnel and said second tunnel intersectwithin said bone.
 7. A method of attachment of tissue to bone asdescribed in claim 1, wherein a portion of said first tunnel is notparallel to said second tunnel at a point of intersection of said firsttunnel and said second tunnel.
 8. A method of attachment of tissue tobone, comprising the steps of: a) arthroscopically forming a firsttunnel in a bone using a first drill guide; b) arthroscopically forminga second tunnel in said bone using a second drill guide, wherein saidfirst tunnel intersects said second tunnel; c) passing a suture thoughsaid first tunnel and said second tunnel, wherein an end of said sutureextends from an opening to said first tunnel and an opposite end of saidsuture extends from an opening to said second tunnel; and d) securingsaid first end of said suture and said second end of said suture overtissue to pull said tissue against said bone.
 9. A method of attachmentof tissue to bone as described in claim 8, wherein said first tunnel isformed using an arcuate drill guide having a lumen therein.
 10. A methodof attachment of tissue to bone as described in claim 9, wherein saidsecond tunnel is formed using a drill guide having a lumen therein. 11.A method of attachment of tissue to bone as described in claim 8,wherein said first tunnel is formed by a flexible stylus that isinserted through said drill guide.
 12. A method of attachment of tissueto bone as described in claim 8, wherein said second tunnel is formed bya stylus that is inserted through said drill guide.
 13. A method ofattachment of tissue to bone as described in claim 8, wherein saidsecond tunnel is formed by a trephine that is inserted through saiddrill guide.
 14. A method of attachment of tissue to bone as describedin claim 11, wherein said flexible stylus has a cutter formed on an endthereof.
 15. A method of attachment of tissue to bone as described inclaim 13, wherein said suture is passed through a lumen in saidtrephine.
 16. A method of attachment of tissue to bone as described inclaim 15, wherein, after said trephine is fully advanced to form saidsecond tunnel, and prior to passing said suture through said lumen insaid trephine, said trephine is partially retracted.